Dataset Information

The association between residency training and internists' ability to practice conservatively.

ABSTRACT:

Importance

Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care.

Objective

To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care.

Design, setting, and participants

Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357).

Exposures

Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program's hospital referral region.

Main outcomes and measures

The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier.

Results

Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P < .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers).

Conclusions and relevance

Regardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.

SUBMITTER: Sirovich BE

PROVIDER: S-EPMC4445367 | biostudies-literature | 2014 Oct

REPOSITORIES: biostudies-literature

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Publications

The association between residency training and internists' ability to practice conservatively.

Sirovich Brenda E BE Lipner Rebecca S RS Johnston Mary M Holmboe Eric S ES

JAMA internal medicine 20141001 10

<h4>Importance</h4>Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care.<h4>Objective</h4>To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care.<h4>Design, ...[more]

PMID: 25179515

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Project description:Importance: Use of health care services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns-in particular, physicians' ability to provide high-quality, high-value care-develop during training, the association of a physician's regional practice environment with that ability is less well understood.Objective: To examine the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians whose practice environment changed due to relocation after residency.Design, setting, and participants: This cohort study included a national sample of 3896 internal medicine physicians who took the 2002 American Board of Internal Medicine initial certification examination followed approximately 1 decade (April 21, 2011, to May 7, 2015) later by the Maintenance of Certification (MOC) examination. At the time of the MOC examination, 2714 of these internists were practicing in a new region. Data were analyzed from March 6, 2016, to May 21, 2018.Exposures: Intensity of care in the Dartmouth Atlas hospital referral region (HRR), measured by per-enrollee end-of-life physician visits (primary) and current practice type (secondary).Main outcomes and measures: The outcome, a physician's ability to practice high-value care, was assessed using the Appropriately Conservative Management (ACM) score on the MOC examination, measuring performance across all questions for which the correct answer was the most conservative option. The exposure, regional health care intensity, was measured as per-enrollee end-of-life physician visits in the Dartmouth Atlas HRR of the physician's practice.Results: Among the 3860 participating internists included in the analysis (2030 men [52.6%]; mean [SD] age, 45.6 [4.5] years), those who moved to regions in the quintile of highest health care intensity had an ACM score 0.22 SD lower (95% CI, -0.32 to -0.12) than internists who moved to regions in the quintile of lowest intensity, controlling for postresidency ACM scores. This difference reflected scoring in the 44th compared with the 53rd percentile of all examinees. This association was mildly attenuated (0.18 SD less; 95% CI, -0.28 to -0.09) after adjustment for physician and practice characteristics.Conclusions and relevance: This study found that practice patterns of internists who relocate after residency training appear to migrate toward norms of the new region. The demands of practicing in high-intensity regions may erode the ability to practice high-value conservative care.

Project description:Importance:Important metrics of residency program success include the clinical outcomes achieved by trainees after transitioning to practice. Previous studies have shown significant differences in reported training experiences of general surgery residents at nonuniversity-based residency (NUBR) and university-based residency (UBR) programs. Objective:To examine the differences in practice patterns and clinical outcomes between surgeons trained in NUBR and those trained in UBR programs. Design, Setting, and Participants:This observational cohort study linked the claims data of patients who underwent general surgery procedures in New York, Florida, and Pennsylvania between January 1, 2012, and December 31, 2013, to demographic and training information of surgeons in the American Medical Association Physician Masterfile. Patients who underwent a qualifying procedure were grouped by surgeon. Practice pattern analysis was performed on 3638 surgeons and 1 237 621 patients, representing 214 residency programs. Clinical outcomes analysis was performed on 2301 surgeons and 312 584 patients. Data analysis was conducted from February 1, 2017, to July 31, 2017. Exposures:NUBR or UBR training status. Main Outcomes and Measures:Inpatient mortality, complications, and prolonged length of stay. Results:No significant differences were observed between the NUBR-trained surgeons and UBR-trained surgeons in age (mean, 53.3 years vs 53.7 years), sex (female, 18.2% vs 16.9%), or years of clinical experience (mean, 16.5 years vs 16.5 years). Overall, NUBR-trained surgeons compared with UBR-trained surgeons performed more procedures (median interquartile range [IQR], 328 [93-661] vs 164 [49-444]; P < .001) and performed a greater proportion of procedures in the outpatient setting (risk difference, 6.5; 95% CI, 6.4 to 6.7; P < .001). Before matching, the mean proportion of patients with documented inpatient mortality was lower for NUBR-trained surgeons than for UBR-trained surgeons (risk difference, -1.01; 95% CI, -1.41 to -0.61; P < .001). The mean proportion of patients with complications (risk difference, -3.17%; 95% CI, -4.21 to -2.13; P < .001) and prolonged length of stay (risk difference, -1.89%; 95% CI, -2.79 to -0.98; P < .001) was also lower for NUBR-trained surgeons. After matching, no significant differences in patient mortality, complications, and prolonged length of stay were found between NUBR- and UBR-trained surgeons. Conclusions and Relevance:Surgeons trained in NUBR and UBR programs have distinct practice patterns. After controlling for patient, procedure, and hospital factors, no differences were observed in the inpatient outcomes between the 2 groups.

Project description:BACKGROUND: Pediatricians and family physicians are responsible for providing newborn resuscitation, yet Accreditation Council for Graduate Medical Education requirements for training in this area during residency differ markedly for the two specialties. Our objectives were to determine (1) the extent to which neonatal resuscitation training differs for pediatric and family medicine residents; (2) the extent to which general pediatricians and family physicians engage in newborn resuscitation in their practice; and (3) whether use of resuscitation skills differs between urban/suburban and rural providers. METHODS: We surveyed a national cohort of pediatricians and family physicians who obtained board certification between 2001 and 2005. Data were analyzed based on type of physician and setting of current practice. RESULTS: Survey response rate was 22% (382 of 1736). Compared with family medicine physicians, pediatricians received more neonatal resuscitation training during residency. Most members of both groups had attended no deliveries in the year prior to the survey (75% [111 of 148] versus 74% [114 of 154]). In their current practice, the groups were equally likely to have provided a newborn bag and mask ventilation, chest compressions, and resuscitation medications. Pediatricians were more likely than family physicians to have attempted to either intubate a newborn (20% [28 of 148] versus 10% [16 of 153]; P = .0495) or insert umbilical catheters (15% [22 of 148] versus 5% [8 of 153]; P = .005). Regardless of specialty, rural physicians were much more likely to report that they attended deliveries (61% [41 of 67] versus 15% [36 of 234]; P < .001). Among rural pediatricians attending deliveries, 44% (7 of 16) reported feeling inadequately prepared for at least one delivery in the past year. CONCLUSIONS: Few primary care pediatricians and family physicians provide newborn resuscitation after residency. For those who do attend deliveries, current training 5 provide insufficient preparation. Flexible, individualized residency curricula could target intensive resuscitation training to individuals who plan to practice in rural areas and/or attend deliveries after graduation.

Project description:BackgroundNeonatal resuscitation is an important skillset for clinicians attending deliveries. Accredited neonatal resuscitation training is not obligatory in most training centers of standardized medical residency programs before 2022 in China. We investigated the feasibility and effectiveness of neonatal resuscitation simulation training (neo-RST) in residents in Shenzhen, China.MethodsFour two-day neo-RST workshops were conducted in the University of Hong Kong-Shenzhen Hospital and Shenzhen Health Capacity Building and Continuing Education Center in 2020-2021. The workshops had Neonatal Resuscitation Program (NRP)® update, skill stations and simulation practice with debriefing. Each participant had the integrated skill station assessment (ISSA) at the end of workshop. Participants of workshops included residents of different disciplines and health care providers (HCPs) of neonatal and obstetrical departments. We compared demographic characteristics, neonatal resuscitation knowledge before training, ISSA overall and categorical scores on skill sets between residents and HCPs.ResultsIn 2020-2021, 4 neo-RST workshops were conducted with 48 residents and 48 HCPs. The residents group had less working experience, less prior experience in neo-RST and lower neonatal resuscitation knowledge scores than those of HCPs group. After the workshop, residents had higher overall ISSA score than that of HCPs group (90.2 ± 5.9 vs. 86.3 ± 6.6%, P = 0.003, respectively). There was no significant difference in the numbers of participants scored <80% in residents and HCPs group (3 [6.3%] vs. 7 [14.6%], respectively). Regarding the categorical scores, residents scored significantly higher in preparation, ventilation, crisis resource management and behavioral skills but lower in appropriate oxygen use, when compared with the HCPs.ConclusionNeo-RST for residents is feasible with promising short-term educational outcomes. Neo-RST could be implemented in standardized medical residency programs in China.

Project description:ObjectivesWith the increased emphasis on personalised, patient-centred care, there is now greater acceptance and expectation for the physician to address issues related to spirituality and religion (SR) during clinical consultations with patients. In light of the clinical need to improve SR-related training in residency, this review sought to examine the extant literature on the attitudes of residents regarding SR during residency training, impact on clinical care and psychological well-being of residents and SR-related curriculum implemented within various residency programmes.DesignA scoping review was conducted on studies examining the topic of SR within residency training up until July 2020 on PubMed/Medline and Web of Science databases. Keywords for the literature search included: (Spirituality OR Religion) AND (Residen* OR "Postgraduate Medicine" OR "Post-graduate Medicine" OR "Graduate Medical Education").ResultsOverall, 44 studies were included. The majority were conducted in North America (95.5%) predominantly within family medicine (29.5%), psychiatry (29.5%) and internal medicine (25%) residency programmes. While residents held positive attitudes about the role of SR and impact on patient care (such as better therapeutic relationship, treatment adherence and coping with illness), they often lacked the knowledge and skills to address these issues. Better spiritual well-being of residents was associated with greater sense of work accomplishment, overall self-rated health, decreased burnout and depressive symptoms. SR-related curricula varied from standalone workshops to continuous modules across the training years.ConclusionsThese findings suggest a need to better integrate appropriate SR-related education within residency training. Better engagement of the residents through different pedagogical strategies with supervision, feedback, reflective practice and ongoing faculty and peer support can enhance learning about SR in clinical care. Future studies should identify barriers to SR-related training and evaluate the outcomes of these SR-related curriculum including how they impact the well-being of patients and residents over time.

Project description:BACKGROUND:Empathy is one of the vital personality attributes for all physicians. It is essential for establishing general interpersonal relationships among doctors and patients. Unfortunately, there is evidence for the decline of physician's empathy during the clinical training phase and is a major concern for medical educators worldwide. One of the major factors reported for the decline of this trait is an unprofessional learning environment. OBJECTIVE:This study examines the relationship between empathy level and perception of climate of professionalism among residents. METHOD:The study participants included 70 residents of Obstetrics & Gynecology and Pediatrics departments of a private sector tertiary care hospital in Karachi, Pakistan. Two self-administered internet based surveys - Jefferson Scale of Physician Empathy (JSPE) and "Professionalism Climate Instrument"(PCI) - were administered to assess the level of empathy among the participants and their perception of professionalism in the learning environment. The relationship between the level of empathy and professionalism was analyzed using Spearman rank correlation. RESULTS:The overall response rate was 81.4% with mean empathy level of 103?±?13. The internal consistency of each scale measured by Cronbach's coefficient ? was 0.76 for JSPE and 0.65 for PCI. No significant difference was observed in the mean empathy scores between senior and junior residents of both specialties. Statistically significant difference in empathy scores existed between female and male residents (p?=?0.012; 95% CI, 2.27 to 17.59). The mean PCI score was 106?+?8.88 with no significant difference among residents of two specialties. Professionalism score was not found to vary with either the year of residency or gender. Empathy score and professionalism climate were not found to be correlated (rs?=?0.56, p?=?0.64). CONCLUSION:The findings suggested that empathy is a relatively stable trait that remains unchanged during residency training programs. Female residents had higher empathic concern than the male trainees, however, the empathy level of the participants was not found to be influenced by the climate of professionalism.

Dataset Information

The association between residency training and internists' ability to practice conservatively.

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Conclusions and relevance

Publications

The association between residency training and internists' ability to practice conservatively.

Similar Datasets

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